Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240602 Renewal 03/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Lifetime medical history states that Individual #2 is followed by an audiologist but there is no record of audiology appointments. The record states that the individual has hearing loss and hearing aids. Staff relayed that the Individual has a history of refusing audiology appointments and breaking/declining to wear hearing aids. However, the individual's assessment does not discuss this information and there is no documentation to support this information in the record.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The lifetime medical history for individual #2 was updated on 3/20/24 to reflect that she had been followed by an audiologist, but the individual has been discharged from the audiologist due to a history of refusing to wear the hearing aids and throwing them away. The annual assessment for individual #2 was also updated on 3/19/24 to reflect that individual #2 has refused to wear her hearing aids and has thrown them away in the past. 03/20/2024 Implemented
6400.181(c)The 1/2/24 annual assessment for Individual #2 is identical to the previous year's annual assessment completed on 1/5/23 so does not reflect the current year's documentation and observations.The assessment shall be based on assessment instruments, interviews, progress notes and observations. The annual assessment for Individual #2 has been re-written on 3/21/24 utilizing the new annual assessment form which was updated based on the 6400 regulations and will be based on assessment instruments such as interviews, progress notes, and observations. 03/18/2024 Implemented
6400.163(a)Individual #2 is prescribed Mucinex 600 mg ER. The container for this medication had no prescription label on it.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The prescription for individual #2 for Mucinex was reordered on 3/6/24. The prescription was filled by the pharmacy and delivered to the home on 3/8/24. 03/21/2024 Implemented
SIN-00201393 Renewal 03/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was no light located in the pull down attic.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. There was no light located in the pull down attic. The light was replaced and repaired on 3/3/22, see attachment#4. 03/03/2022 Implemented
6400.112(a)The October fire drill was not completed at inspection. An unannounced fire drill shall be held at least once a month. An unannounced fire drill shall be held at least once a month. The October fire drill was not completed at inspection. All supervisors were retrained on fire drill requirements on 3/17/22 by the Director. All supervisors will retrain the DSPs at each location by 3/31/22. 03/31/2022 Implemented
6400.141(c)(14)Physical for individual#1 did not contain pertinent diagnosis information in the event of an emergencyThe physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical for individual #1 did not contain pertinent diagnosis information in the event of an emergency. The physical form submitted during inspection stated "N/A" (written by the doctor)under medical information pertinent to diagnosis and treatment in case of an emergency, see attachment #6. DEC's team review all of the medical documents for individual #1 as it is pertinent to her medical diagnoses. She does not currently have any "emergency" treatment needs. At her most recent neurology appointment it was determined that she has no aneurysm on her brain, see attachment #5. In her ISP it was stated that in the event of a seizure, 911 would need to be called as a result of the previously diagnosed aneurysm. This is no longer a concern and the Program Specialist emailed the Supports Coordinator to remove this information from her ISP on 3/18/22. 03/18/2022 Implemented
SIN-00130364 Renewal 01/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons were not locked in the basement.Poisonous materials shall be kept locked or made inaccessible to individuals. Poisonous materials shall be kept locked or made inaccessible to individuals. All of the individuals at the site are able to safely use or avoid poisonous materials. Each individual¿s assessment and ISP supports their ability to safely use or avoid poisonous materials. All individuals at this site are aware of poisonous material and do not require them to be locked up according to their assessments and ISP. See attached assessments. 03/23/2018 Implemented
6400.67(a)The radiator panels were rusted in the master bathroom. The electrical outlet was partially sticking out of the living room wall.Floors, walls, ceilings and other surfaces shall be in good repair. Floors, walls, ceilings, and other surfaces shall be in good repair. The outlet was fixed on 2/15/18; the baseboards were fixed on 2/26/18. Staff will be retrained on 3/29/18 on site safety checklist completion and how to appropriately identify potential repairs or hazards. 02/26/2018 Implemented
6400.105Lighter fluid was found in the basement among the cans of paint.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. The lighter fluid was removed immediately on 01/30/18. Site safety checklists include this regulation as a checkpoint. All site supervisors were retrained in this regulation on 3-23-18. The Assistant Director of CRD will monitor site safety checklists and complete a monthly site check beginning March 15, 2018. 01/30/2018 Implemented
6400.142(f)There was no dental plan in the record for individual #1.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Each individual must have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. A dental hygiene plan was created and reviewed for implementation for individual #1 on 3/13/18. The Program Specialist was retrained on 3-13-18 in the requirements for dental hygiene plans. All files will be reviewed and updated by 4/30/18. 03/13/2018 Implemented
6400.181(d)(2)Individual #1's DOA was 11/5/16 and a revision was not completed for the update of the outcomes.The plan lead shall develop, update and revise the ISP according to the following: The initial ISP shall be developed within 90 calendar days after the individual's admission date to the facility. The admission¿s checklist was reviewed and updated to include all required timelines for paperwork of a new admission to the program. The timeline for new admission paperwork was reviewed with the new Program Specialist on 3-15-18. The Program Specialist is responsible for maintaining the timeline and ensuring all paperwork is completed within the appropriate time frame. The CRD Director will oversee all files of new admissions to ensure the timeline is followed. 03/15/2018 Implemented
SIN-00107140 Renewal 01/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was paint peeling in multiple areas varying in size from a dime to approximately a foot in length on the walls in Individual # 1's bedroom. There was peeling paint approximately one foot by four feet in size on the wall near the closet.Floors, walls, ceilings and other surfaces shall be in good repair. Clean and sanitary conditions will be maintained in the home. This bedroom was repaired and repainted. Cork board hung on one wall for pictures and a white board for drawing for the individual to use. Staff retrained in the site safety checklist and their responsibility. Supervisors responsible to ensure safety checklist are submitted and correct. CRD Director or ACRD Director will complete unannounced house checks for cleanliness. 3/30/2017 Implemented
6400.76(a)There was a tear approximately a foot in length exposing the wood on the foot rest of the recliner located int he living room. There was peeling and worn fabric on the left arm on the recliner located in the living room. Furniture and equipment shall be nonhazardous, clean and sturdy. Furniture and equipment will l be nonhazardous, clean and sturdy. The chair was replaced on 2/5/2017 Attached is the receipt. . Staff will be retrained in the site safety checklist and their responsibility to ensure compliance by April 1 2017. Supervisors responsible to ensure safety checklist are submitted and correct. CRD Director or ACRD Director will track non compliance and ensure corrected. Completed site safety for February 2017 attached to show compliance. Attachment #9 04/28/2017 Implemented
SIN-00086986 Renewal 11/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)In individual #1's bedroom the rocking chairs left arm rest was broken. Furniture and equipment shall be nonhazardous, clean and sturdy. The rocking chair was repaired on 11/19/15. Furniture and equipment shall be nonhazardous, clean and sturdy. During house meetings, individuals reminded to inform staff of furmniture needing repaired in their bedrooms. For the individuals that locked their rooms, staff will ask to complete the site safety checklist with them on a monthly basis. Addendum #5. 12/01/2015 Implemented
SIN-00063497 Renewal 07/01/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)The Program Specialist (Staff D) was hired on 10/31/13; however was not trained in the program specialist responsibilities. The program specialist shall be responsible for the following: Coordinating and completing assessments. On 8/5/14, the program specialist was trained in program specialist responsibilities and the PS Addendum to Program Specialist's Job Description was added to the hiring packet for CRD to ensure all future PS are trained in their responsibilities upon hire. Human Resources will reveiw staff files to ensure that job responsibilites are made aware to all program specialists. 08/05/2014 Implemented
6400.151(a)Staff C's previous physical examination was dated 7/3/11; the most recent physical examination was dated 8/28/13. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff physical examination will be completed every 2 years. Tracking system is in place via the Human Resources Department. Staff C's examination was completed prior to 10/20/14. Notification of physical exams being due will be sent in a email to the staff's supervisor. CRD Director monitors the completion of physicals with time frames on monthly basis. Additionally, a software sytem has been purchased to track all phyicals. 07/14/2015 Implemented
SIN-00049759 Renewal 07/01/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)Individual #1's assessment, dated 1/13/13, was not sent to the supports coordinator(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The program specialist shall provide to the SC, as applicable, and the plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update, and revision of the ISP. Upon review this assessment was sent by e-mail to the Support Coordinator ES. Failure to document this on the assessment form and/or print e-mail to file led to the determination it was not disseminated. As part of restructuring the management team and adding more managers a new program specialist was hired and trained. A checklist has been created and will be used by the Program Specialist and will be submitted to the CRD Director for review after the completion of each assessment. Dissemination date will be recorded on the assessment. There was one assessment (SM) due since inspection and it was dissemination to all team members on 07/18/2013 which is 30 days before the ISP Meeting is schedule. 08/01/2013 Implemented
6400.183(5)Individual #1's social, emotional and environmental plan was last updated on 2/10/12. (5) A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. A protocol to address the social, emotional, and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. PS when writing assessments was not including the SEEP Plans as they are not part of the assessment. However this led to the oversight of updating SEEP Plans at the time of the ISP. A master list of all individuals requiring SEEP Plans has been created. A protocol for writing SEP Plans has been developed and implemented. The SEEP Plans will be updated at the time of the assessment and approved by the CRD Director. A full review of all files was completed by 8/15/2013 and SEEP Plans as required will be completed by 9/15/2013. The SEEP Plan for MP was written on 07/15/2013 and disseminated to the team. 09/15/2013 Implemented
6400.186(c)(1)Individual #1's monthly ISP reviews were not completed for the months of 3/13, 2/13, 1/13, and 12/12(c) The ISP review must include the following: (1) A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months towards ISP outcomes supported by services provided by the residential home. Procedure and tracking form in place for the Program Specialist to track monthly progress and the completion of 3 month reviews. Random checks of files will take place throughout the year to assure compliance as well as review by the CRD Director. 08/26/2013 Implemented